Provider-Based Billing

Altru Health System is a provider-based health system designated by the Center for Medicare and Medicaid Services (CMS) in Title 42 Code of Federal Regulations (CFR). Provider-based billing is a type of billing for services provided in a clinic or department which is considered to be part of the hospital. This change will affect patients with Medicare, Medicare Advantage, Tricare/Veterans Administration and Minnesota Medical Assistance plans.

Depending on a patient's specific insurance coverage, it is possible that some benefits may differ for these services and procedures. Patients will also see two claims on billing statements which breaks apart the professional services (clinic visit charge) from the technical service (hospital charge).

This may be confusing to patients. Explanatory brochures will be available at the registration desks to help answer questions. Patients should review their insurance benefits or contact their insurance provider to determine what their policy will cover and identify any out-of-pocket expenses.

If you have questions about provider-based billing or items on your statement, please call (701)780-1500 or (800)464-7574 (toll-free). You may also view a page illustrating the difference you will see on statements.

What is provider-based billing?

Provider-based billing is a type of billing for services provided in a clinic or department which is considered to be part of the hospital. This is often the case with large healthcare systems. Clinics located several miles away from the main hospital campus may be considered part of the hospital. Even though you’re seeing your regular physician in a clinic setting and not actually “hospitalized,” your visit is billed under the hospital rather than the physician’s office.

What is different?

Affected patients will see charges split on their statements for each provider-based visit – one charge will be a professional fee (clinic charge) and the other a technical fee (hospital charge).

The combined total charge is the same, but the components are split apart. Depending on specific insurance coverage, it is possible that some benefits may differ for these services and procedures. Some patients may have to pay a higher cost because a portion of the billed service is being charged as a hospital charge.

The increase in cost is a result of the health plan’s co-insurance and deductible (not an increase in actual charges). Patients with a supplement plan are not likely to see much change.

Are all patients being billed this way?

No. The requirement for breaking out charges for each office visit was set by the Centers for Medicare and Medicaid (CMS). Thus, only patients with Medicare, Medicare Advantage, Tricare/Veterans Administration or Minnesota Medical Assistance insurances are being billed using provider-based billing. At this time, private (commercial) insurance companies do not require this breakout.

How this affects patients with private health insurance?

It is important that you ask your health insurance company the following questions:

Many private health insurance companies do not require that we follow the same billing rules as Medicare and Medicaid. If you have private (commercial) health insurance, the hospital component of the physician office visit is billed as part of the physician bill and is processed by the health insurance company under the patient’s physician benefits.

How does this affect secondary insurance coverage?

Co-insurance and deductibles may be covered by a secondary insurance. Check with your health insurance company for more details.

If you would like assistance applying for secondary coverage, please contact our HERO Program at (701)780-5060.

Why does Altru Health System choose to have this designation?

This is the national model of practice for large, health care networks where the hospital owns space and employs support staff who assist with patient care. It has been adopted by many medical centers, both locally and across the country.

This benefits patients as all departments of the hospital are subject to strict quality standards and are monitored by Joint Commission Accreditation of Healthcare Organizations (JCAHO), an independent, not-for-profit organization that accredits and certifies healthcare organizations and programs in the United States.

Center for Medicare and Medicaid Services (CMS) has distinct payment programs for provider-based billing, and require that we make it clear to the public which practices are part of the hospital.

Will appointments be different?

Clinical care will not change. Patients will continue to see their regular doctor and healthcare team and continue to receive excellent quality care. Scheduling appointments and tests will be handled as they have been in the past.

What are Medicare Secondary Payer (MSP) questions and how does it affect me?

Altru, as a participating Medicare provider, is required to screen Medicare patients according to MSP rules. At each visit, Medicare patients will be asked 10-15 questions. The intent is to help clarify if Medicare or another insurance pays first. We recognize this may feel repetitive but it is a government requirement.

What can you do if you are having difficulty paying for health care services?

Our financial assistance policy exists to help qualifying patients. Information is available by calling 701.780.1500 or 800.464.7574 (toll-free).

In addition, we can assist with other county, state or national coverage programs that patients may be eligible for by calling 701.780.5060.